Authors (including presenting author) :
Tsoi YP, Kwan MY, Lee PM, Leung PH
Affiliation :
Department of Obstetrics and Gynaecology, Princess Margaret Hospital
Introduction :
Modern technology of In- Patient Medication Order Entry (IPMOE) could enhance medication safety by preventing drug prescribing and administration error. However the key element is to ensure end user well-known each function of the system in order to secure patient safety. A medication incident of drug omission was happened in April 2019, in which 2 drugs were omitted for 1 dose each for twelve hours. And it was noted that nurses were unfamiliar with the usage of the “Withhold” Admin Function in IPMOE.
Objectives :
1. To identify the factors leading to the medication incident
2. To develop improvement strategies to close the loophole
Methodology :
A small working group was formed to explore the causes of the incident by using the fishbone diagram. Two main causes were identified. Firstly, staff were unfamiliar with the “Withhold Admin Function in IPMOE” and did not aware the meaning of “withhold profile” was referred to withheld all drugs in all routes e.g. IV, oral. Secondly, insufficient communication patient’s drug profile was noted in nurse’s shift handover.
Result & Outcome :
Improvement strategies including (i) in what condition and how to use the “Withhold” Admin Function” were narrated in detail to staff; (ii) countercheck of patient’s drug profiles at before and after activation of the withhold button; (iii) marked the withheld drug name and the duration on the special instruction card which is placed in patient’s folder to alert all staff, and (iv) reinforce counterchecking patient’s drug profiles in IPMOE during shift handover. These all were discussed, developed and implemented in order to stop the incident from happening again. System of regular monitoring and review by shift in-charge, together with spot check on staffs’ compliance are in place. The overall compliance rate was over 90%. Although it was just a small change, but it ensures medication safety and no medication incident related to “Withhold Admin Function” was reported after the improvement work, and in turn it enhances quality of care.
This project has successfully established a concrete system to safeguard error-prone areas of medication safety in a sustainable manner.
